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8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf
1/12
J 28, 2011 115"" A A "&A ""A
Ab'&acFLDQ, F MHL G L &A MDFK GJ LLJLEFL G GEHDL FLJGEFD FLGFKK F HMDK. G MDF F LJ GJ DD NJ-LGFK F GDGQ, FLEJGD JKKLF HLLJFK, H-LFL JLJKLK F HJKFLLGF, DL J FJEMJKEFL KQKLEK F EFQ JFL GMFLJK. &FL KGJL LE L &A MDFK N F ND-D, FMEJ G HJLD DFD KKMK N F
JK Q HQKFK JJF FLJHJLLGF G LMDFK. EF LD KKMK G L FO &A MDFK J KJ K GDDGOK:
MLGJK G L &A MDFK HJKFL JGE-EFLGFK GJ L GDDGOF KMJGMHK G \GEHD-LW &A&: GEEMFLQ-IMJ FLJ-GEFD F-LGFK G ED-LG-EGJL F KNJLQ FDL J-KKGL FLJ-GEFD FLGFK (FGFJD LJLEFL JGEEFLGFK, GFDQ FGJELGFGML FLEJGD LJHQ G KH JKKLFL L-JD KGDLK). JGE DFD HGFL G NO, \GEHD-LW &A& J LLJ JFLL FLG HJEJQ, K-GFJQ (GEEMFLQ-IMJ F HGKLGHJLN) F
LJLJQ HJLGFLK. GK J L DFD HJKFLLGFKG &A& K KF F L EJFQ JGGE, L FJD OJ F GF &. MLMJ FLGL LJLEFL KLMKG &A& OGMD EGJ DFDDQ JDNFL LQ F-DM HLFLK F KLMK GJ L Q F KLQ G FLGLK GJ L LJLEFL G L GN EFLGFGJEK G &A&, JLJ LF GFMLF KLMK K GFL NM LJE \GEHDLW FLJ-GEFD F-LGFK.
FO &A MDFK GJ L LJLEFL G J-KKLFL LJ D LG EFLGF EFQ G FO NDDJMK, DLGM DFD L GJ L LJLEFL G \GEHDL &A&W OL FO KMKLFK PKL. MJLJ-EGJ, LJLEFL JGEEFLGFK GJ &A& MK Q
" J FGL FDM. K JGMH G KKK GE-HJKK FGM HLFLK (.. L FLJ JGMH G HGKLGH-JLN F LJLJQ HJLGFLK, JMJJFL FLJNFLGFK
F D ML KMJJQ GJ FJGLRF HFJLLK) LG HJG- N KH JGEEFLGFK GJ KM FLEJGDLJLEFL.
A HFD G "MJGHF GDDMK JGE KMJJQ, F-LFKN J, DFD EJGGDGQ F FLGMK K-KK K NDGH JGEEFLGFK K GF LGN EFLGF DFD FLLK OL L E G HJG- NF DJ LJHML JGEEFLGFK GJ KHDFD FGKK. AF FNMD HLFL-FLJ H-
HJG GJ LK NJQ EHGJLFL JGMH G KKK OL KMKLFLD EGJLQ F EGJLDLQ K KKFLD GJGHLED FLEJGD LJLEFL.
"A"
FLDQ, F MHL G L &A MDFK GJ LLJLEFL G GEHDL FLJGEFD FLGFKK F HMDK 1. K GEHJFKN GMEFLK F LGJGMDQ GDDL Q JCFGOF PHJLK FL D F LK FDMF PLFK ODD QGF LA, ECF L OGJDO GD KLFJ EEL-DQ LJ HMDLGF. GONJ, L K MDF, F FG
MDF F LJ GJ DD NJLGFK F GDGQ, FLE-JGD JKKLF HLLJFK, HLFL JLJKLK FHJKFLLGF, DL J F JEMJKEFL KQKLEKF EFQ JFL GMFLJK. &F L KGJL LE LMDFK N F MK DFDDQ, KNJD JK G GFMKGF N JKF F F FL. GDDGOF KM GKJNLGFK F HJKGFD PHJFK, HFD G "MJGHF GDDMK JGE KMJJQ, FLFKN J, DF-D EJGGDGQ F FLGMK KKK EL KNJDLEK LG KMKK L HJGDEL KKMK KKGL OLL FO &A MDFK.
GDDGOF JGEEFLGFK F GKJNLGFKGF NJQ EHGJLFL JGMH G KKK OL KMKLF-LD EGJLQ F EGJLDLQ J FGL EFL LG KLF F
GFLJL LG L &A MDFK, ML JLJ LG KGE FGJELGF F MF GJ L EFEFLG GEHDL FLJ-GEFD FLGFK OJ L
"MJ K (2011) 16: 115-126 T &. GDRHD MDKJK 2011
A&&b&A "A" \&A"W &A- Ab&A&"& A " " &A $&"&" V
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1HJLEFL G $FJD, KJD F GJ MJJQ, DFCME F, AE GKHLD G D FNJKLQ FFGNJ, $JEFQ 2GQD EHKJ GKHLD, FKLJ, FL FGE
3HJLEFL AFKLK FELGF, GHLD bL DM bJFJ, AKKKLF MDIM GHLMP JK F MFNJKL JK && FK JGL , J K, JF
4&FKLLML G AFLEJGD EGLJHQ, EGDFKC LL D AEQ, MKK5HJLEFL G MJJQ, LGD FNJKLQ, GDDFG A. $EDD, GE, &LDQ
8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf
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MLGJK DN L GMD G NDM GJ DFFK LJL-F LGK HLFLK. EF GFLFLGMK KKMK F LJFL &A MDFK J K GDDGOK:
&" 1 V "&&&
&A FK GEHDL F MFGEHDL F-
LJ-GEFD FLGFK. &F GEHDL FLJ-GE-FD FLGFK L FLGF PLFK QGF L GD-DGO NKMK G GJF FLG L HJLGFD KH F KKKGL OL LJ KKK GJELGF GJ HJLGFLK, OJK F MFGEHDL FLGF FNGDNK FLJ-EMJD FDEELGF G L KLJGFLKLFD LJL 1.
K HHJK LG F JLD JFLLGF OGK FGL DOQK LJFKDL FLG DFD JDLQ. GJ F-KLF, HLFL OL F HHFLK OL LH G -JF GF LGH G L HHFP (KKME EGJLDLQ: 0.5-2%) K \GEHDLW &A& GJF LG LK F-LGFK OJK DGKLJME D-KKGL GDLK OL -JGLQH 027 (EF EGJLDLQ: 20-30%) K F
\MFGEHDLW &A& GDDGOF L &A JLJ. AGEHDL &A& K F KL Q LK GMJK F DF-D KNJLQ F FGL FKKJDQ Q LK DGD PLFL. JGJ, L GN EFLGF FLGF KGMD MK OL MLGF.
MLGJK G L &A MDFK HJKFL LJL-EFL JGEEFLGFK GJ L GDDGOF JDQ -F KMJGMHK G \GEHDLW &A&: GEEMFLQ-IMJ FLJ-GEFD FLGFK G ED-LG-EGJ-L F KNJLQ F DL J-KKGL FLJ-GEFD FLGFK. J J FG FJD EHJDLJLEFL JGEEFLGFK, GFDQ FGJELGF GF F-LEJGD LJHQ G KH JKKLFL LJ.
JGE DFD HGFL G NO, \GEHDLW &A&
J LLJ JFLL FLG HJEJQ, KGFJQ (GE-EMFLQ-IMJ F HGKLGHJLN) F LJLJQ HJ-LGFLK 2. GK J L DFD HJKFLLGFK G &A&K KF F L EJFQ JGGE, L FJD OJ FGF &. &F JFLDQ HMDK EFMKJHLK DF OL JLD GFLGFK F &A& L MLGJK N J-JJ LG L GN EFLGF FLGFK 3, 4. JGJ, L K EM DGKJ LG DFD GFLGFK MDFK GDDGO LK DKKLGF. HFD DNKLL MJLJ KLMK GF FLEJGD FLK F &A&KGMD FGL DGFJ JJ LG \GEHDLW F \MFGE-HDLW K LK DK LG EPLMJ G NJQ JFLDFD FLLK F LJGJ EQ OCF L NDM G
LK KLMK. &L OGMD EGJ MJL F MLMJ LGFDM HLFLK F KLMK GJ L Q F KLQ G FLGLK GJ L LJLEFL G GEEMFLQ--IMJ KGFJQ HJLGFLK, HGKLGHJLN KGFJQ HJLGFLK F LJLJQ HJLGFLK, JKHLNDQ, JLJLF LG GFML KLMK K GF L NM LJE\GEHDLW FLJ-GEFD FLGFK.
&" 2 V "&A b A"&A, A&b&&&"& A A&b&& "A&
M LG L KMKLFLDDQ FJKF, ML GJHDDQ NJQF HJNDF G JKKLFL $JE-HGKLN F$JE-FLN HLGFK LJ N F FMEJGMK
GJLK LG FGMJ JKJ F L NDGHEFL G FO FLEJGDK OL Q F KLQ F LK D5. AK JKMDL, FO FLGLK OL Q FKL J-
KKLFL LJ (DFRGD FKL A F ", H-LGEQF FKL A F ", LQDF FKLA, ", "b-HJGMF "FLJGLJ,JHFE-JKKLFL LJ) N KGOF LNLQ F NLJG F F NNG 6, 7, 8. FGJLMFLDQ, L FO &AMDFK GJ L LJLEFL G JKKLFL LJ KME-EJR F LD GML LJLEFL G \DL-J K-
KGL GEHDL FLJ-GEFD FLGFW D LGEFLGF FQ G LK JMK 1, DLGM DFD LGJ L LJLEFL G \GEHDL &A&W PKL GJ DF-RGD F LQDF O K HHJGN GJ \&A&W 8-10, 11*, 12* (*=HMDK LJ L &A MDFKN F HMDK). JLFDQ, L DFD L GJ DDG L EFLGF JMK F \&A&W J OC F GF-JFK GML F FJK EGJLDLQ JL MFJ LQ-DF LJLEFL JEF (GJ \&A&W L EGJLDLQ JL OK 0.7% (FGF-KFFLDQ) J F L LQDFJGMH LF F L GEHJLGJ JGMH) 8, 13. GONJ,JFGER GMD DF LJDK GJ L Q FKLQ G F FLGL F L LJLEFL G \&A&W
MK Q JKKLFL GJFKEK KM K A, " GJ"b-HJGMF "FLJGLJ J MFDCDQ LG JJ GML. GFKIMFLDQ, K DGF K EGJ LF GFLJHML DLJFLN K NDD, L HHDLGF G FLGL NJKLQ HHJK LG NJQ MKMD LGGD FGJJ LG JM L FLGL KDLN HJKKMJ GF FQ KMKLF K HJL G F FLGL KLOJKH HJG-JE 14-17. &L K FHHJGHJL LG JKLJL LJLEFLJGEEFLGFK GJ A F &A& LG NFGEQFF GJ "b-HJGMF "FLJGLJ LG J-HFEK F HHJDDF/LRGLE 1. A JGE-EFLGF LL FDMK L PKLF NJLQ G FL-GLK OL DFD L JGE L LJLEFL F &A& (NF-GEQF, DFRGD F LQDF GJ A, DFRGD
F LQDF GJ ", JHFEK, HHJDDF/LRGLE, LQDF F GDKLF GJ "b, K D 5) HJGNK G LOF KMKLFK F LJEKG F FNMD HHJG LG NJQ HLFL OL EF-ERLGF G LGPLQ F JKKLF NDGHEFL.
&" 3 V ", AbA""A"-&$ A$", AcinetobActer .
FO &A MDFK G FGL FDM FQ LJL-EFL JGEEFLGFK GJ &A& MK Q ". MLGJK G L MDF KJ GFDQ HLFLK KM KDNJ LJFKHDFL JHFLK OL F FLJ-GEFD F-
LGF GJFLF F L HLGDJQ LJL GJ HLFLKCFGOF LG GDGFR OL " K JKC LGJ. &FL, L NDM G L EFKLJLGF G F FL-FLJG-GD FL GJ L HJGFGKK G HLFLK OL &A& KKMKK GFLJGNJKD, ML L FLJ JGMH G HGKL-GHJLN F LJLJQ HJLGFLK, JMJJFL FLJNF-LGFK F D ML KMJJQ, FJGLRF HFJLLK, FLGK OL NDNMDJ JL KK GJ HJGKLL F-LJNKMDJ ELJDK N KMKLFLD JKC (NJQF JGE GMFLJQ LG GMFLJQ F JGE GKHLD LG GKH-LD) GJ FNGDNEFL G " O K JKC LGJ GJLJLEFL DMJ F L. K JGMH G KKKGEHJKK FGM HLFLK LG HJGN KH JGE-EFLGFK GJ KM FLEJGD LJLEFL. K
J KGOF F D 5, K ODD K JGEEFLGFK GJL LJLEFL G HFEK-HJGMF LJF A! '* # +a! # KHH.
""A A "&A ""A116 J 28, 2011
8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf
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&& A "A" &&"
&FLJ GEFD FLGFK (&A&) J GEEGF. -LGFD F FLJFLGFD LKK KGO LL GF FGMJ KK G KNJ KHKK GJ KHL KGC K MKQ &A&. &L K L KGF EGKL GEEGF GMK GKHL KGC LJ HMDEGFJQ MKK 18-20. ADEGKL
90% G DD FLJ GEFD FLGFK J KG DDKGFJQ HJLGFD FLGFK F JIMJ HJEJDQ KMJD HHJG (.. HHFLGEQ GJ HJGJL- HHFLK). J K GNJODEF NFGJ FLGL LJLEFL GEHJ LG HDG F LKKK JGMH 21. GONJ, HJEJQ FIMLF FHHJGHJL FLGL JEFK N KMKLF-LDDQ OGJK HJGFGKL GMLGE GJ HLFLK OL &A&F MK KMKLFLD FJK F DL J GKLK 22-24.
GEEFLGFK GJ L EHJD FLGL LJL-EFL G &A& J K GF EMDLLM G HJGKHLNJFGER F GFLJGDD KLMK. GEHDL &A&,
Q FLGF, J FGL FKKJDQ KNJ KK. &FLJDK KF GJ KGOF IMNDF G FLGLKGJ MK GJ JKLJLGF G FO FLGLK L YMKMDZFLJ-GEFD FLGFK FJGDD J KKGL OL
F AA" && KGJ LOF 4 F 6. AEF LGKGO LJHML IMNDF, NF L JKMDLK G JFL GJF FDQKK OJ FGL D LG EGFKLJLKMHJGJLQ G FQ HJLMDJ FLGL GJ LJLEFLKE 21.
&F LK EFMKJHL NJQ FLGL / JGMH G F-LGLK K HJGN OL KH DND G NF
F KLJFL G JGEEFLGF KGOF O KEG LJ 25, 26 F KGOF F D 1. DNDG NF GDDGOK L IMDLQ G KLMK GJ L KH- JM, L KLJFL G JGEEFLGF LCK GF-KJLGFK G LGPLQ F HGLFLD GJ NDGHEFLG JKKLF FLG GMFL.
GGKF L JL FLGLK GJ HJLMDJ H-LFL KGMD FDMF Q EMDLLM G LGJK,.. HLFLK (G-EGJLK, EEMFG-KMHHJKKGF, HJ- NGMK FLEJGD LJLEFL), PHL EJGDKHLJME, DGD LJD F JKKLF KLLKLK, KG HHDLGF, DND G LGPLQ F GKLK.
&F JFL QJK L NDMLGF G FLGL LJL-
EFL KEK OJ EHJGN LJGM JFLLF HJLGFLK KMJGMHK. K MDFK GDDGO LDFD FLGFK G HJEJQ, KGFJQ F LJLJQ HJLGFLK (DK 2-4), K GF 35. &FJKF
""A A "&A ""AJ 28, 2011 117
ta(# 1. NDK G NF F KLJFL G JGEEFLGF EG LJ 25, 26.
Le*e #f e*ide"ce E$a"ai#"
1 L-FDQKK G JFGER GFLJGDD LJDK, GG IMDLQ JFGER GFLJGDD LJDK GJ YDD
GJ FGFZ KLMK F O FG LJLEFL K FGL F GHLGF
2 YGO IMDLQZ JFGER GFLJGDD LJDK (
8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf
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FMEJK G &A& MK Q EMDL-JKKLFL FLK(A, ", "b-HJGMF "FLJGLJ)
GJ MDL LJLD KHK (.. P#"+)+*a , ca*"'- "a ) OJ GEEGL Q PLJ L (DK 5, 6).
""A A "&A ""A118 J 28, 2011
ta(# 3. GEEFLGFK GJ FLD LJHQ G JFL GJEK G KGFJQ HJLGFLK. b&=bL-DLEK FLGJ,A=LDDF JKKLFL . MJMK, "= FGEQF-JKKLFL "FLJGGMK KHH., "b= PLF KHLJME L-DL-EK HJGMF KHK, EL.=ELJGFRGD, + = GEFLGF OL FLGLK GNJF JE FLN F FJG KHKJIMJ, #= GEFLGF OL KMGEGFK-LN FLGLK JIMJ KMGEGFK K KMKHL; *=MK FLGL GFDQ DGD KMKHLDLQ JLK J U90%.
Diag"#'i' Like #&ga"i'! I"iia he&a$ Le*e #f e*ide"ce S&e"gh #f&ec#!!e"dai#"
C#!!"i-ac%i&ed "FLJGLJ HDGKHGJF JGMH 2 /3 1/1 A/A
#caied $e&i#"ii' "FLJGG + ELJGFRGD
(e.g. &ece" $e&f#&aed AFJGK AEFGHFDD F/b& 1 A
a$$e"dicii') AQDEFGHFDDF/b& 1 A
HJGDGPF* + L. 1 b
C#!!"i-ac%i&ed "FLJGLJ HDGKHGJF JGMH 3 + 1 A
diff'e $e&i#"ii' "FLJGG ELJGFRGD
+- &i'k fac#&' AFJGK AQDEFGHFDDF/b& 1 A
(e.g. $e&f#&aed c##"ic &EHFE-DKLLF 1 A
ca&ci"#!a) JGHFE 1 A
GJHFE 1 A
"JLHFE 1 AGPDGPF 1 A
QDF 1 b
HE 1 b
HJGDGPF*+ L. 1 b
NGDGPF* + L. 1 b
N#'#c#!ia "FLJGLJ &EHFE-DKLLF 1 A
$#'#$e&ai*e, $#'- "FLJGG JGHFE 1 A
&a!aic #& $#'- AFJGK GJHFE 1 A
i"e&*e"i#"a diff'e LHQDGG AQDEFGHFDDF/b& 1 A
$e&i#"ii' "JLHFE# 1 A
(e.g. a"a'#!#ic QDF# 2 A
eakage f##i"g GPDGPF 1 b
ie#&a"'*e&'#'#!) A
" K D 5
"b
F KHH. K D 6
ta(# 4. GEEFLGFK GJ L FLD LJHQ G LJLJQ HJLGFLK. #= GEFLGF LJHQ OL HKMGEGFK-LNFL JIMJ KMGEGFK K KMKHL
Diag"#'i' Like #&ga"i'! I"iia he&a$ Le*e #f e*ide"ce S&e"gh #f&ec#!!e"dai#"
Pe&'i'i"g $e&i#"ii' "FLJGLJ &EHFE-DKLLF 2 A
de'$ie ade%ae ("FLJGG) JGHFE 2 A
'&gica a"d i"iia (LHQDGG) AQDEFGHFDDF/b& 2 A
a"i!icbia he&a$ AFJGK QDF# 2 A
"JLHFE# 4 b
LJPGF+ 4 b
LJGFRGD
A, "
"b K D 5
KMGEGFK KHH.
F KHH. K D 6
8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf
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J J FG JDD L QL JJF LJLEFLMJLGF G &A&. GDDGOF JGEEFLGFK JK GF LJHQ FLJNDK KLL F JFGEK KLM-K, FGKL JLJKLK G J LF FLGMKFLK (.. ca*"'"a KH.), OLJ L FLGF K DGD
GJ KQKLE, K ODD K L MLGJZK PHJF. F-NJ L HLFL K EHJGNF DFDDQ F FDEE-LGJQ KFK JKF, L FLGL KGFLFMLGF
KGMD GFKJ, KHDDQ LG HJNFL HLGFKDLGF F MFKJD K LK. K LJLEFLKMKK, NF F KNJ FLGFK, FGL GMJJ LJ 7QK, L LJLEFL KGFLFMLGF KGMD GFK-J F NGMJ G JHL MDLMJ KEHDF, KHDDQ
LG HJNFL KDLGF G EMDL-JKKLFL HLGFK FHGKKD LGP K LK. ALGFD EF HJG-MJK, KJ G GLJ G G FLGF, F G KM-
""A A "&A ""AJ 28, 2011 119
ta(# 5. DMDL F LJL FLGL LJHQ OL KMKHL GJ HJGNF &A& OL EMDL-JKKLFL FLK (A=LDDFJKKLFL . MJMK, "= FGEQF-JKKLFL "FLJGGMK KHH., "b= PLF KHLJME L-DLEK HJGMF KHK, + = GEFLGF OL FLGLK GNJF JE FLN F FJG KHK JIMJ, # = GEFLGF OLKMGEGFK-LN FLGLK JIMJ KMGEGFK K KMKHL; [ = FG EGFGLJHQ, * =MK FLGL GFDQ DGD KMK-HLDLQ JLK J U90%.
Age" A"ibi#ic Le*e #f e*ide"ce S&e"gh #f &ec#!!e"dai#"
MRSA QDF# 2 AFRGD+ 3 AHLGEQF+ 4
FGEQF+ 4 bGLJEGPRGD+ 4
VRE QDF# 2 AFRGD+ 3 A
ESBL-$dci"g &EHFE 3 A(E. c#i, Keb'iea '$$.) JGHFE 3 A
GJHFE 3 A"JLHFE# 3 A
QDF# 2 A AQDEFGHFDDF/b& 3 A
GKGEQF[ 4 bP'ed#!#"a' '$$. &EHFE 4 A
JGHFE 4 AGJHFE 4 A
AQDEFGHFDDF/b& 4 AHE 4 A
AEFGDQGK[ 4 bHJGDGPF* 4 ANGDGPF* 4 A
Aci"e#bace& '$$. GDKLF 2 A QDF# 4 A
Ca&ba$e"e!a'e- QDF# 4 A $dci"g '$ecie' GDKLF 4 b
(i.e. KPC )
ta(# 6. JLEFL KLJLQ OL KMKHL GJ HJGNF FNKN FLJ-GEFD EQGL FLGF OL F KHH.
Diag"#'i' I"iia he&a$ Le*e #f e*ide"ce S&e"gh #f &ec#!!e"dai#"
C##"iai#" ih Ca"dida '$$. FGF 3 A
S'$eced #& $*e" i"*a'i*e DMGFRGD 3 A
!c#'i': 'abe $aie" GJGFRGD 4 b
S'$eced #& $*e" i"*a'i*e "FGFF 4 A
!c#'i': i"'abe $aie" (AFMDMFF,
KHGMFF, MFF)& F KHH. K
DMGFRGD-KMKHLD,
LH-GOF LJHQ LG
DMGFRGD GJ 3 A
GJGFRGD 3 A
8/20/2019 antimicrobial treatment of complicated intraabdominal infections and the new IDSA guidelines.pdf
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KIMFL J-GHJLGFK J GLJ KKMK LG JKK FLK KLLF.
JLGFLK K L EGKL JIMFL GJE G &A& GFKL-LMLK NJQ GEHDP JLGF G L HJLGFME FLK KLGDGD KLJMLMJ LG LJD, NJD, MFD GJED KLEMD. J EF GJEK G HJLGFLK F JFLL GJF LG LK MKLN HLGF-
KK, LK KHLJME G HLGFK F GJF LG KMJ-D F FLEJGD LJHQ 2:
&A "&&&
JEJQ (KHGFLFGMK LJD) HJLGFLK (b) GF-KLLMLK GFDQ GML 1% G DD HJLGFLK KK 27. BMNFD GJE K LK GJF F ELGFGMK KHJFLGF, MKMDDQ KLJHLGG, HFMEGG GJ NJQ JJDQ Ha#)+&'( '*$(#*a# . &F MDLK F L EBGJ-LQ G KK (70%), b K KKGL OL KLK FDGGD-KKGL DNJ JJGKK GJ GLJ MKK G JM EEMF KQKLE (30%). &L K FGK OF
L KLK FMLJGHD GMFL PK 250/MD 28. &FEGKL KK, L GFKLLMLK EGFG FLGF LJGMLJFKDGLGF GJ ELGFGMK KHJF. &F KLMKHGJLJQF L DFD KLLF JDKLDDQ, GFDQ F GML35% G KK L MKLN FL K KGDL F LFKJ EGF e. !+ (' , K(#'#((a ., KLHQDGG, F-LJGG GJ KLJHLGG. FKMFL JL G -LJD LLGF K PHDF LJGM L L LL FL DFD KLLF GFDQ GML 50% G KK OL bKLK K JNKL GJ MDLMJD LKLF 28.
JEJQ HJLGFLK F LMJMDGKK K MKMDDQ MKQ ELGFGMK KHJF.
FGEK LJDK GJ b LJLEFLK J JJ.GKL G L KLMK J JLJGKHLN OGJCK LL
KGMD DKK K LJLEFL KMJNDDF LJDK. GDDGOF JGEEFLGFK LMK G FGL KMHHGJLJ NF DNDK (D 2). AFLGLK MK OJLJPGF, GLPE, LRE K ODD K Q-DEFGHFDDFK OL FL-L-DLEK LNLQ 28-31. L LK FLK DFD MJ JLK G MH LG 83% OJ N.
"&&& A&A" & A
A KKGL HJLGFLK K MKMDDQ MK Q LM-GJ LLJ GFLEFLGF. GKL JIMFLDQ FNGDNMKLN FLK J GMDK-FLN KLHQDGG
F Sa&(+!+!! a# . LJ DKK JIMFL F- NGDN FLK J e. !+ (' , FLJGG, GLJ KLJHLG-G, P#"+)+*a a#%'*+a , FJGK, e*# +a! # KHH., A! '* # +a! # KH., P+# KH. GJ ca*"'"a KHK32. FGEHDL KK F LJL KMKKMDDQ Q F FLEJGD FLK LG L DQKK DM.FDQ F JJ F KJGMK KK FLGLK N LG NF FGL GFDQ FLG L HJLGFME ML HJFLJD K ODD. &F HLFLK OL JFD DMJ HHDL JMKN LG EGFLGJ F GKK BMKL. JGE-EF EHJD LJHQ K MKMDDQ KLJL OL NF-GEQF HDMK FLEF GJ JGMH 2 HDGKHGJF OL GJ OLGML HJGDGPF 33. LJHQ KGMD LF GFLFM LJ LJGDGQ JKMDLK N F
GLF. &F KK OL HJGNF A-, "- F"FLJGG (FD. ") FLGFK, FLGLK F D 4 KGMD HHD. &F KK OL HJGNF EQ-
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KKMD KMJD LJLEFLK G &A& OL FLLJDLJLEFLK OLGML FLJGGD GNJ 36, 37, 46."FLJGG-GNJF FLGLK J JGEEF FHLFLK OL HGKL-GHJLN HJLGFLK, LJLJQ HJ-LGFLK, KNJ KHKK G GEFD GJF F FLGL- HJLJLEFL GJ FGJLK-HJGF HLFLK (J-LGFLK F JL NDN JHDEFL) 37. &F DD LK
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7. AJL , C L D. KLQ F Q G H-LGEQF GJ L LJLEFL G GEHDL KCF F KCF-KLJMLMJ FLGFK. DF &F K 2004; 38: 1673-1681
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